8.2 Orthopedic Examination: Extremities
Key Takeaways
- The Lachman test, performed with the knee flexed 20 to 30 degrees, is the most sensitive clinical test for an anterior cruciate ligament (ACL) tear; a soft or absent endpoint with increased anterior tibial translation is positive.
- Phalen test and Tinel sign at the wrist both screen for carpal tunnel syndrome; a positive finding is paresthesia in the median nerve distribution (thumb through radial half of the ring finger).
- Cozen test uses resisted wrist extension; Mill test uses passive stretch of the common extensor origin — both detect lateral epicondylitis, and confusing active versus passive mechanics is a classic Part II trap.
- A positive Finkelstein test — pain over the radial styloid when the wrist is ulnarly deviated with the thumb tucked in the fist — indicates de Quervain tenosynovitis of the abductor pollicis longus and extensor pollicis brevis.
- The Thompson test (absent plantarflexion when the calf is squeezed in the prone patient) indicates a complete Achilles tendon rupture; the ankle anterior drawer test assesses the anterior talofibular ligament after inversion sprain.
8.2 Orthopedic Examination: Extremities
Extremity special tests are among the most heavily tested material in the Neuromusculoskeletal Diagnosis domain on NBCE Part II because they translate cleanly into clinical vignettes: the stem describes a provocative maneuver and asks you to name the test, identify the structure stressed, or select the implied diagnosis. Your job is to know each test's position, direction of force, positive finding, and the one condition it most strongly indicates. The boards love near-miss pairs — Cozen versus Mill, Lachman versus anterior drawer, Phalen versus Tinel — and dermatomal or nerve-distribution questions that follow an orthopedic finding.
Shoulder Tests
Impingement
- Neer test: The examiner stabilizes the scapula and passively forward-flexes the internally rotated arm. Pain indicates subacromial impingement of the supraspinatus tendon or subacromial bursa.
- Hawkins-Kennedy test: The arm is flexed to 90 degrees and forcibly internally rotated. Pain confirms impingement as the greater tuberosity is driven under the coracoacromial arch.
Rotator cuff and biceps
- Empty can (Jobe) test: Arm abducted 90 degrees in the scapular plane, thumb down; downward resistance. Weakness or pain indicates supraspinatus pathology.
- Speed test: Shoulder flexed 90 degrees, elbow extended, forearm supinated; patient resists downward force. Pain in the bicipital groove indicates biceps tendon pathology.
- Yergason test: Elbow flexed 90 degrees, forearm pronated; patient resists supination. Pain or tendon snapping in the bicipital groove suggests biceps tendinitis or SLAP labral injury.
Instability
- Apprehension test: Supine, arm abducted 90 degrees and externally rotated. A look of apprehension or guarding (not mere pain) is positive for anterior glenohumeral instability. The relocation test applies posterior force; relief of apprehension confirms the finding.
Elbow Tests
| Test | Mechanism | Positive finding | Diagnosis |
|---|---|---|---|
| Cozen | Resisted wrist extension, elbow extended | Lateral epicondyle pain | Lateral epicondylitis |
| Mill | Passive wrist flexion, forearm pronation, elbow extension | Lateral epicondyle pain | Lateral epicondylitis |
| Tinel at cubital tunnel | Percussion over ulnar nerve posterior to medial epicondyle | Tingling digits 4–5 | Cubital tunnel syndrome |
The Part II trap: Cozen is active (resisted); Mill is passive (stretch). Both target the extensor carpi radialis brevis origin. Medial epicondylitis (golfer's elbow) is tested with resisted wrist flexion and pronation.
Wrist and Hand Tests
- Phalen test: Wrists held in full flexion for up to 60 seconds. Median-distribution paresthesia (thumb, index, middle, radial half of ring finger) indicates carpal tunnel syndrome.
- Tinel at carpal tunnel: Percussion over the median nerve at the distal wrist crease reproduces median paresthesia.
- Finkelstein test: Fist with thumb enclosed; ulnar deviation of wrist. Pain over the radial styloid indicates de Quervain tenosynovitis (first dorsal compartment: APL and EPB).
Hip Tests
- Trendelenburg sign: Standing on one leg; contralateral pelvis drops. Indicates gluteus medius weakness (superior gluteal nerve, L5) or hip instability.
- Thomas test: Supine, one knee to chest; opposite thigh should remain flat. Elevated thigh indicates hip flexion contracture (tight iliopsoas).
- Ober test: Side-lying, hip abducted and extended; failure to adduct indicates ITB tightness.
- FADIR test: Hip flexion, adduction, internal rotation. Groin pain suggests femoroacetabular impingement or labral tear.
Knee Tests
| Test | Position | Positive finding | Structure |
|---|---|---|---|
| Lachman | Knee flexed 20–30°; anterior tibial pull | Soft/absent endpoint, increased translation | ACL (most sensitive) |
| Anterior drawer | Knee flexed 90°; tibia pulled forward | Excessive anterior translation | ACL (less sensitive) |
| Posterior drawer | Knee flexed 90°; tibia pushed back | Excessive posterior translation | PCL |
| McMurray | Full flexion → extension with rotation | Painful click at joint line | Meniscal tear |
| Valgus stress | 0° and 30° flexion | Medial gapping/pain | MCL |
| Varus stress | 0° and 30° flexion | Lateral gapping/pain | LCL |
Critical distinctions: Lachman outperforms the anterior drawer because hamstrings and the meniscus can mask ACL laxity at 90 degrees. Collateral laxity at 30 degrees isolates the collateral ligament; laxity in full extension implies additional cruciate or capsular injury.
Ankle and Foot Tests
- Ankle anterior drawer: Ankle slightly plantarflexed; calcaneus drawn forward. Excessive translation indicates ATFL rupture (most common inversion sprain ligament).
- Thompson (Simmonds) test: Prone patient, calf squeezed. Absent plantarflexion indicates complete Achilles tendon rupture.
Connecting Orthopedic Tests to Neuroanatomy
Part II often chains an orthopedic finding to a nerve or myotome:
- Empty can weakness → supraspinatus (C5–C6, suprascapular nerve)
- Trendelenburg drop → gluteus medius (L5, superior gluteal nerve)
- Carpal tunnel paresthesia → median nerve (C6–C7)
- Foot drop after knee injury → peroneal nerve (L4–L5), not ACL tear alone
Part II Traps
Do not confuse sensitivity with specificity when stems ask which test is "most sensitive" — Lachman for ACL, SLR for radiculopathy. Avoid mixing active and passive test mechanics (Cozen vs. Mill). Remember that apprehension (instability) differs from impingement pain (Neer/Hawkins). Finally, a positive Phalen or Tinel identifies median nerve compression at the wrist, not cervical radiculopathy — though both can coexist, the test localizes the entrapment site.
A 34-year-old tennis player has lateral elbow pain. The examiner asks the patient to extend the wrist against resistance with the elbow extended and forearm pronated, reproducing pain over the lateral epicondyle. Which test was performed?
A 19-year-old athlete twisted his knee. With the knee flexed approximately 25 degrees, the examiner stabilizes the femur and pulls the tibia forward, noting increased anterior translation with no firm endpoint. Which structure is most likely injured?
A 30-year-old new mother has radial-sided wrist pain. She makes a fist with her thumb inside her fingers, and the examiner ulnarly deviates the wrist, producing sharp pain over the radial styloid. This finding is most consistent with which condition?
A 48-year-old recreational basketball player felt a pop in his posterior ankle and cannot push off. Prone with feet off the table, calf squeeze produces no plantarflexion. What is the diagnosis?